66. A client with a history of a myocardial infarction (MI) reports calf pain. What should a nurse assess first?
66. A client with a history of a myocardial infarction (MI) reports calf pain. What should a nurse assess first?
. Ability to complete a stress test.
. Effects of climbing a flight of stairs.
. Information related to the precipitating event.
. Response to dorsiflexion of the foot.
Test-Taking Tip
Thrombophlebitis is the concern. Look for a nursing action (e.g., testing for Homans' sign) that is the first step in the nursing process and assess for a thrombosis.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because a stress test would not be indicated if a thrombosis is suspected. Answer 2 is incorrect because assessing whether or not stair climbing elicits pain would not help the nurse determine the possible presence of a venous thrombosis. Answer 3 is incorrect because verbal information would not help the nurse to determine the possible presence of a venous thrombosis. Answer 4 is correct because, in a client with a history of MI, there is always a risk of thrombophlebitis from immobility or arrhythmias. If Homans' sign (dorsiflexion of the foot) is negative, the nurse can proceed with other assessments.